MEDICAL FEE SCHEDULE

Section 10: Physical Medicine

Physical medicine is an integral
part of the healing process for a variety of injured workers. Recognizing this,
this schedule includes codes for physical medicine, i.e., those modalities,
procedures, tests, and measurements in the physical medicine section, codes
97001 through 97750, also unlisted code (97799) representing specific
therapeutic procedures performed by licensed physicians, licensed physical
therapists, licensed occupational therapists, a licensed PT assistant under the
direction of a licensed physical therapist, a certified occupational therapist
assistant under the direction of a licensed occupational therapists or by
support personnel under direct supervision of a licensed provider. The following
criteria must be met in all cases where physical medicine is rendered in order
for a service to quality for reimbursement.

A. PHYSICAL MEDICAL ASSESSMENT

An assessment must be performed to determine if a patient will
benefit from physical medicine therapy.

When a physician examines a patient and an assessment for physical
medicine is performed, the billing for the office visit includes the
physical medicine assessment.

B. QUALIFICATIONS FOR REIMBURSEMENT

The patient’s condition must have the potential for restoration of
function.

The treatment must be specific to the injury and have the potential to
improve the patient’s condition.

C. PLAN OF CARE

An initial plan of care must be developed and filed with the payer
regardless of whether therapy is provided by a physician or practicing
therapist. The content of the plan of care, at the minimum, should
contact:

The specific therapists to be provided, including the frequency and
duration of each

The estimated duration of the therapeutic regimen

Preparation of care plan does not warrant a separate fee

A plan of care must be updated at least every 30 days, and the
revised plan must be signed by the physician or therapist and submitted
to the payer.

D. REIMBURSEMENT

Visits for therapy may not exceed one visit per day without prior
approval from the payer.

Therapy exceeding 30 visits must have preauthorization from the payer
for continuing care. It must meet the following guidelines:

The treatment must be medically necessary

Telephone approval is appropriate. Documentation should be made by
the provider in the patient’s medical record indicating the date and
name of the payer representative giving authorization for the continued
therapy.

Modalities are now divided into two groups: “supervised”
and “constant attendance.” Supervised modalities will be reimbursed as
billed for only one unit per visit. Constant attendance modalities will
be reimbursed as billed in units of 15 minutes. Appropriate rounding up
or down is expected through professional judgment. Excess in units will
be subject to utilization review

E. FOLLOW-UP EXAMINATION OF AN ESTABLISHED PATIENT

A physician, physical therapists, or occupational therapist may
charge and be reimbursed for a follow-up examination for physical
therapy only if new symptoms present the need for reexamination and
evaluation as follows:

There is a definitive change in the patient’s condition

The patient fails to respond to treatment and there is a need to
change the treatment plan

The patient has completed the therapy regimen and is ready to
receive discharge instructions

F. TESTS AND MEASUREMENTS

Reimbursement for extremity testing, muscle testing, and range of
motion measurements (95831, 95832, 95834, 95851, 95852 (97750) will not
be made more than once in a 30-day period for the same body area.

When two or more procedures from 95831 through 95852 are performed on
the same day, reimbursement may not exceed the maximum reimbursement
allowance (MRA) for the procedure code 95834, total evaluation of the
body, including hands.

Procedure code 97750 must be used when testing is performed by means
of mechanical equipment.

Procedure code 97750 includes a printout of test results and separate
reimbursement must not be made under CPT code 99090.

Functional capacity testing must have preauthorization from the
carrier before scheduling the tests. Reimbursement will be per your
agreement with the insurance carrier or self insurer. CPT code EV100
must be used. See industrial Rehabilitation Section for additional
information on evaluations.

G. FABRICATION OF ORTHOTICS

Procedure code 97760 must be billed for the professional services of
a physician or therapists to fabricate orthotics.

Orthotics, prosthetics, and related supplies used may be billed under
code 99070 and may not exceed a 20 percent mark-up of the provider’s
cost. An invoice may be required by the carrier before reimbursement is
made.

H. TENS UNITS

TENS (transcutaneous electrical nerve simulation) must be provided and
under the attending or treating physician’s prescription.

Authorization from the payer must be sought before purchase or rental
arrangements are made for TENs. The payer has sole right of selection of
vendors for rental or purchase of equipment, supplies, etc.

I. SUPPLIES, EQUIPMENT, ORTHOTICS, AND PROSTHETICS

Physicians and therapists must obtain authorization from the payer
before purchase/rental of supplies, equipment, orthotics, and
prosthetics.

The payer has sole right of selection of vendors.

Reimbursement for supplies and equipment must not exceed 20 percent
above the provider’s costs. An invoice may be required by the carrier
before reimbursement is made.

J. OTHER INSTRUCTIONS

Charges will not be reimbursed for publications, books, or video
cassettes unless by prior approval of the payer.

All charges for services must be clearly itemized by CPT code. State
professional license number must be on the bill.

Documentation may be required by the payer to substantiate the
necessity for treatment rendered. Documentation to substantiate charges
and reports of tests and measurements are included in the fee for the
service and do not warrant additional reimbursement.

When patients do not show measurable progress, the payer may request
the physician to discontinue the treatment or provide documentation to
substantiate medical necessity.

K. CHRONIC PAIN PROGRAM AND BACK SCHOOLS

All
chronic paid programs or back schools shall require preauthorization from the
payer. The payer and the chronic paid program or back school program may agree
upon the daily, weekly, or other time-based payment to be made for services
provided to the injured/ill worker. This agreement shall supersede the use of
this physical medicine section when calculating reimbursement but shall not
exceed the usual and customary fee. These charges may be paid by insurance
carrier or self insured per agreement.

The CPT Code BT100, which the Commission used in the past for back testing,
has been eliminated; and you should advise the Providers to use CPT Code
97750 and this code requires
time. We have received inquiries regarding approvals of CPT Code 97750 for
Physical Therapy. CPT Code 97750 is used to represent physical performance
testing or measurements in units of 15 minutes. More than one unit may be
allowed for this code. 97750 replaced former codes 97720, 97721, and 97752.
These codes were replaced per the 1995 edition of
Current Procedural Terminology. The N.C. Industrial Commission Medical
Fee Schedule, Physical Medicine Section F, states that 97720, 97721, and
97752 are to be used only once for the same body area within a 30-day
period. The same applies for code 97750. However, there may be a reason
testing has to be done twice in 30-day period (e.g., when such testing was
ordered by the treating physician). When billing for Functional Capacity,
the Medical Provider must use the Code EV100 and this is to be paid per
agreement. These bills are not to be sent to the Industrial Commission for
calculation, because they are to be paid per agreement.

For physical therapy, you must enter a time in total
minutes for most CPT codes. The provider must be a licensed physical
therapist or occupational therapist. Codes 97010 through 97028
will not require the time to be entered and
only one of each of the above codes will be allowed per day. You can
allow more than one of these codes per visit, but not the same code more
than once during the same visit. OHT01 has been eliminated and occupational
therapists must use physical therapist codes. (See new 1996 Medical Fee
Schedule for changes in time). Billing an extra fee for electrodes is
allowed for iontophoresis code 97033 only.